Debbie Emberly

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Due to public health restrictions, the COVID-19 pandemic required significant changes in the delivery of mental health services. The use of virtual care for balancing access with treatment needs requires a shared decision between clients, caregivers, and clinicians. One aspect for consideration is the length of treatment and whether it differs by treatment modality. Therefore, it is essential to quantify and compare episodes of care conducted virtually and in-person, while accounting for individual and system level factors that may influence length of episodes. Objective: To operationalise a means of measuring episodes of care using administrative data to improve our understanding of how treatment modality impacts treatment duration for children and adolescents accessing Community Mental Health & Addictions services at IWK Health. Methods: Episodes of care were created using administrative data collected by the IWK Mental Health and Addictions program. A multilevel mixed-effects negative binomial model and time-to-event analysis were used to model the association between treatment modality and treatment duration, both in visits and days, adjusting for client and system characteristics. A zero-inflated negative binomial model was used to analyze the association between treatment modality and the ratio of days to visits within an episode of care. Results: Virtual episodes of care had more visits compared to in-person episodes between April 1, 2020, and March 31, 2021, whereas between April 1, 2022, and March 31, 2023 virtual episodes of care were associated with fewer visits. These patterns were consistent after adjusting for client and system characteristics. Additionally, there was no significant difference in the ratio of days to visits between the virtual and in-person treatment modalities throughout each time period, indicating intersession wait times were not driving any differences in the treatment lengths in days between the modalities. Conclusions: To our knowledge, this is the first study to examine the association between treatment modality and treatment duration. While initially longer than in-person episodes of care, over time the average length of episodes conducted mainly virtually has attenuated, perhaps due to growing comfort with the technology or client factors not adequately captured in administrative data. This information can be valuable to clinicians, clients, and their families regarding expected treatment timelines and aid in informing service planning.

BACKGROUND Due to public health restrictions, the COVID-19 pandemic required significant changes in the delivery of mental health services. The use of virtual care for balancing access with treatment needs requires a shared decision between clients, caregivers, and clinicians. One aspect for consideration is the length of treatment and whether it differs by treatment modality. Therefore, it is essential to quantify and compare episodes of care conducted virtually and in-person, while accounting for individual and system level factors that may influence length of episodes. OBJECTIVE To operationalise a means of measuring episodes of care using administrative data to improve our understanding of how treatment modality impacts treatment duration for children and adolescents accessing Community Mental Health & Addictions services at IWK Health. METHODS Episodes of care were created using administrative data collected by the IWK Mental Health and Addictions program. A multilevel mixed-effects negative binomial model and time-to-event analysis were used to model the association between treatment modality and treatment duration, both in visits and days, adjusting for client and system characteristics. A zero-inflated negative binomial model was used to analyze the association between treatment modality and the ratio of days to visits within an episode of care. RESULTS Virtual episodes of care had more visits compared to in-person episodes between April 1, 2020, and March 31, 2021, whereas between April 1, 2022, and March 31, 2023 virtual episodes of care were associated with fewer visits. These patterns were consistent after adjusting for client and system characteristics. Additionally, there was no significant difference in the ratio of days to visits between the virtual and in-person treatment modalities throughout each time period, indicating intersession wait times were not driving any differences in the treatment lengths in days between the modalities. CONCLUSIONS To our knowledge, this is the first study to examine the association between treatment modality and treatment duration. While initially longer than in-person episodes of care, over time the average length of episodes conducted mainly virtually has attenuated, perhaps due to growing comfort with the technology or client factors not adequately captured in administrative data. This information can be valuable to clinicians, clients, and their families regarding expected treatment timelines and aid in informing service planning.

Introduction: Goal‐oriented practices involve practitioners working collaboratively with clients to identify, develop and focus on objectives for the therapeutic work. It has been suggested that the key mechanism underpinning goal‐oriented practices with young people is the development of epistemic trust via the foundation of open communication, along with shared decision‐making: including young people in decisions about their care. However, goal‐oriented work in practice is variable in scope and content, with no research consensus on what it entails, the mechanisms of change and reported outcomes. Method: This research aims to map the extent, range and nature of the evidence‐base for goal‐oriented practices, including gaps, through a synthesis of the available empirical evidence from the past 20 years. A scoping review of 9783 studies published from 2003 onwards was conducted. Results: In total, 116 studies were identified for inclusion in the review, focusing on goal‐oriented practices specifically related to the mental health and wellbeing of children and young people aged 0–18 (including caregivers as relevant). Alongside presentation of the key elements of the included studies, three themes were developed relating to the features of mental health and wellbeing goal‐oriented practice in the contexts of the studies: Conceptual and Empirical Constructs of Goal‐Oriented Practices, Quality and Making ‘Good’ Goals, and The Socio‐Cultural Contexts of Goal‐Oriented Practice. Conclusion: Several areas for future research are identified that will build on this evidence, and further understanding in this area. Work towards the development of best practice principles will move practice towards transparency in the understanding and delivery of goal‐oriented practices.

Objective To describe patterns of virtual and in-person outpatient mental health service use and factors that may influence the choice of modality in a child and adolescent service. Design A pragmatic mixed-methods approach using routinely collected administrative data between 1 April 2020 and 31 March 2022 and semi-structured interviews with clients, caregivers, clinicians and staff. Interview data were coded according to the Consolidated Framework for Implementation Research (CFIR) and examined for patterns of similarity or divergence across data sources, respondents or other relevant characteristics. Setting Child and adolescent outpatient mental health service, Nova Scotia, Canada. Participants IWK Health clinicians and staff who had participated in virtual mental healthcare following its implementation in March 2020 and clients (aged 12–18 years) and caregivers of clients (aged 3–18 years) who had received treatment from an IWK outpatient clinic between 1 April 2020 and 31 March 2022 (n=1300). Participants (n=48) in semi-structured interviews included nine clients aged 13–18 years (mean 15.7 years), 10 caregivers of clients aged 5–17 years (mean 12.7 years), eight Community Mental Health and Addictions booking and registration or administrative staff and 21 clinicians. Results During peak pandemic activity, upwards of 90% of visits (first or return) were conducted virtually. Between waves, return appointments were more likely to be virtual than first appointments. Interview participants (n=48) reported facilitators and barriers to virtual care within the CFIR domains of ‘outer setting’ (eg, external policies, client needs and resources), ‘inner setting’ (eg, communications within the service), ‘individual characteristics’ (eg, personal attributes, knowledge and beliefs about virtual care) and ‘intervention characteristics’ (eg, relative advantage of virtual or in-person care). Conclusions Shared decision-making regarding treatment modality (virtual vs in-person) requires consideration of client, caregiver, clinician, appointment, health system and public health factors across episodes of care to ensure accessible, safe and high-quality mental healthcare.

Background: Mental health and addictions (MHA) care is complex and individualized and requires coordination across providers and areas of care. Knowledge management is an essential facilitator and common challenge in MHA services. Objective: This paper aimed to describe the development of a knowledge management system (KMS) and the associated processes in 1 MHA program. We also aimed to examine the uptake and use, satisfaction, and feedback on implementation among a group of pilot testers. Methods: This project was conducted as a continuous quality-improvement initiative. Integrated stakeholder engagement was used to scope the content and design the information architecture to be implemented using a commercially available knowledge management platform. A group of 30 clinical and administrative staff were trained and tested with the KMS over a period of 10 weeks. Feedback was collected via surveys and focus groups. System analytics were used to characterize engagement. The content, design, and full-scale implementation planning of the KMS were refined based on the results. Results: Satisfaction with accessing the content increased from baseline to after the pilot. Most testers indicated that they would recommend the KMS to a colleague, and satisfaction with KMS functionalities was high. A median of 7 testers was active each week, and testers were active for a median of 4 days over the course of the pilot. Focus group themes included the following: the KMS was a solution to problems for staff members, functionality of the KMS was important, quality content matters, training was helpful and could be improved, and KMS access was required to be easy and barrier free. Conclusions: Knowledge management is an ongoing need in MHA services, and KMSs hold promise in addressing this need. Testers in 1 MHA program found a KMS that is easy to use and would recommend it to colleagues. Opportunities to improve implementation and increase uptake were identified. Future research is needed to understand the impact of KMSs on quality of care and organizational efficiency.

Objectives The Choice and Partnership Approach (CAPA) was developed to create an accessible, child-centred and family-centred model of child and adolescent mental health service delivery that is adaptable to different settings. We sought to describe the state of evidence regarding the extent, outcomes and contextual considerations of CAPA implementation in community mental health services. Design Scoping review. Data sources Published and grey literature were searched using MEDLINE, Embase, CINAHL, PsycINFO, Scopus and Google to 13 and 20 July 2022, respectively. Eligibility criteria We included reports focused on the implementation, outcomes (clinical, programme or system) or a discussion of contextual factors that may impact CAPA implementation in either child and adolescent or adult mental health services. Data extraction and synthesis Data were extracted using a codebook that reflected the five domains of the Consolidated Framework for Implementation Research (CFIR) and reviewed for agreement and accuracy. Data were synthesised according to the five CFIR domains. Results Forty-eight reports describing 36 unique evaluations were included. Evaluations were observational in nature; 10 employed pre–post designs. CAPA implementation, regardless of setting, was largely motivated by long wait times. Characteristics of individuals (eg, staff buy-in or skills) were not reported. Processes of implementation included facilitative leadership, data-informed planning and monitoring and CAPA training. Fidelity to CAPA was infrequently measured (n=9/36) despite available tools. Health system outcomes were most frequently reported (n=28/36); few evaluations (n=7/36) reported clinical outcomes, with only three reporting pre/post CAPA changes. Conclusions Gaps in evidence preclude a systematic review and meta-analysis of CAPA implementation. Measurement of clinical outcomes represents an area for significant improvement in evaluation. Consistent measurement of model fidelity is essential for ensuring the accuracy of outcomes attributed to its implementation. An understanding of the change processes necessary to support implementation would be strengthened by more comprehensive consideration of contextual factors.